Provider Demographics
NPI:1427353598
Name:SULLIVAN, CHERYL A (FNP)
Entity type:Individual
Prefix:MS
First Name:CHERYL
Middle Name:A
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:CHERYL
Other - Middle Name:A
Other - Last Name:WENDELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:707 N LOGAN AVE
Mailing Address - Street 2:DANVILLE POLYCLINIC, LTD.
Mailing Address - City:DANVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61832-4360
Mailing Address - Country:US
Mailing Address - Phone:217-477-4784
Mailing Address - Fax:217-477-4704
Practice Address - Street 1:707 N LOGAN AVE
Practice Address - Street 2:DANVILLE POLYCLINIC, LTD.
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-4360
Practice Address - Country:US
Practice Address - Phone:217-477-4784
Practice Address - Fax:217-477-4704
Is Sole Proprietor?:No
Enumeration Date:2011-01-20
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209008516363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201080250Medicaid
IL$$$$$$$$$001Medicaid
IL$$$$$$$$$001Medicaid
IN201080250Medicaid